MANAGEMENT OF PATIENTS UNDERGOING LONG-TERM CORTICOTHERAPY.
I/GENERAL AND CLASSIFICATION: Natural glucocorticoids are secreted by the human body in low doses and at a circadian rhythm (70% being secreted between 2 and 8 a.m.). Cortisone and cortisol (or hydrocortisone) are used mainly in hormone replacement therapy for adrenal insufficiency .
Synthetic glucocorticoids have increased activity to allow better anti-inflammatory action and their mineralocorticoid effects are very reduced. They are used in other therapeutic indications (anti-inflammatory, immunosuppressive, anti-allergic) and are defined as:
- short-acting corticosteroids (prednisone, prednisolone, methylprednisolone): anti-inflammatory potency of 4-5 (measured by reference to that of cortisol rated at 1);
- intermediate-effect corticosteroids (triamcinolone, paramethasone): anti-inflammatory power of 5-10;
- Long-acting corticosteroids (betamethasone, dexamethasone, cortivazol): with an anti-inflammatory power of 25-30 (up to 60 for cortivazol).
II/ ACTION OF GLUCOCORTICOIDS: The different actions are:
- increased carbohydrate and protein metabolism
- anti-inflammatory
- antipyretic (reduces fever)
- analgesic (pain reliever)
- anti-allergic (non-immediate action against the effects of contact with an allergen in an allergic subject)
- decreased immune defenses (useful in the fight against graft rejection).
- bronchodilators
- regulator of mucus secretion
III/ MAIN FAMILIES:
- hydrocortisone: hydrocortisone 20mg
- prednisone: cortancyl R a 5 mg
- prednisolone: solupred at 5 mg and 20 mg
- methylprednisolone: medrol R 4 mg
- trimcinolone: kenacort R a 4 mg
- betamethasone: celestene R at 0.75 mg
- dexamethasone: dectancyl R a 0.75 mg
IV/ MAIN INDICATIONS:
- systemic inflammatory diseases: rheumatoid arthritis, acute rheumatic fever, Steven Jackson’s lupus disease, etc.
- Severe vasculitis: Horton’s disease, Behçet’s disease, etc.
- Adrenal insufficiency: Addison’s disease….
- Others: asthma, multiple sclerosis, etc.
V/ GENERAL REPERCUSSIONS TO TAKE INTO ACCOUNT:
- Metabolic complications: diabetes, hypertension, hypokalemia and hyperlipidemia.
- Cortisone-induced osteoporosis
- Skin effects: skin atrophy and delayed healing
- Infectious complications: reactivation of a latent infectious focus, herpes or shingles
- Neuropsychiatric disorders: underlying neurosis and psychosis.
VI/ ORAL RECOVERIES : mycoses, and reactivation of an oral infection focus.
VII/ POTENTIAL RISKS:
- Risk of infection if dosage > 10 mg/day equivalent to prednisone
- Drug risk if combined with NSAIDs
- Risk of acute adrenal insufficiency crisis
VIII/ GENERAL PRECAUTIONS :
- Contact the treating physician
- Limit patient stress through psychological and/or sedative preparation
- Ensure sufficient analgesia
- Be aware of drug interactions
- Be careful if patient is taking bisphosphonates.
IX/ CLINICAL SITUATIONS:
- Long-term corticosteroid therapy < 10 mg/day equivalent to prednisone: all treatments are possible while respecting general precautions .
- Long-term corticosteroid therapy > 10 mg/day equivalent to prednisone:
- Non-invasive procedures:
– conservative care
– non-bloody prosthetic care
– removal of stitches
– installation or adjustment of ODF devices
– taking intraoral x-rays
CAT: GENERAL PRECATIONS MUST BE RESPECTED.
- Invasive procedures: all procedures involving manipulation of the gum, pulp, or apical region of the tooth or in the event of damage to the oral mucosa (apart from local or loco-regional anesthesia)
1-acts not involving mucosal and/or bone healing: general precautions must be observed
2-acts involving mucosal and/or bone healing: respect general precautions and apply the following anti-infective protocol:
- start antibiotic therapy one hour before the procedure
- orally: 2 g amoxicillin in adults and 50 mg/kg amoxicillin in children.
- Or if allergic to Betalactams. Orally: 600 mg of clindamycin in adults and 20 mg/kg of clindamycin in children from 6 years old
- Continue antibiotic prophylaxis for 7 to 10 days.
- Antiseptic mouthwash based on 0.12% chlorhexidine from the 3rd day.
VI/ PRECAUTIONS REGARDING ANESTHESIA : none
VII/ PRECAUTIONS REGARDING PRESCRIPTIONS : do not prescribe NSAIDs.
MANAGEMENT OF PATIENTS UNDERGOING LONG-TERM CORTICOTHERAPY
Bibliography
SFCO. Perioperative management of patients treated with antithrombotics in oral surgery. 2013. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKE
Devillier P. Pharmacology of glucocorticoids and ENT pathologies. Presse Méd 2001; 30: 59-69. 29
SFMBCB. Recommendations for the prescription of anti-inflammatory drugs in oral surgery in adults. 2008 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKE.
MANAGEMENT OF PATIENTS UNDERGOING LONG-TERM CORTICOTHERAPY
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